Nokea
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
- A. Blood urea nitrogen 50 mg/dl
- B. Hemoglobin of 10.3 mg/dl
- C. Venous blood pH 7.30
- D. Serum potassium 6 mEq/L
Correct Answer: D
Rationale: Serum potassium 6 mEq/L. Although all of these findings are abnormal, the elevated potassium level is a life-threatening finding and must be reported immediately.
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A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?
- A. Increase oral fluid intake
- B. Encourage visits from family and friends
- C. Keep conversations short
- D. Monitor vital signs frequently
Correct Answer: C
Rationale: Keep conversations short. Keeping conversations short will promote the client's comfort by decreasing demands on the client's breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, it may increase demands on the client's energy. Monitoring vital signs is an important assessment but not related to promoting the client's comfort.
A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?
- A. Chest pain
- B. Pallor
- C. Inspiratory crackles
- D. Heart murmur
Correct Answer: C
Rationale: Inspiratory crackles. In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of inefficient cardiac pumping.
The client is admitted with a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which precaution should be implemented to prevent spreading the infection to health care workers and other clients?
- A. Wearing a mask within 3 feet of the client
- B. Placing the client in a private room
- C. Wearing an N95 respirator mask
- D. Ensuring a negative-air-pressure room
Correct Answer: B
Rationale: B: A private room prevents MRSA transmission via contact. A, C: Masks are unnecessary for MRSA. D: Negative air pressure is for airborne precautions.
The nurse is wearing PPE. Place the steps to removing the PPE in the correct sequence.
- A. Remove gown
- B. Remove gloves and perform hand hygiene
- C. Remove mask
- D. Remove eye protection
- E. Perform hand hygiene
Correct Answer: B,D,A,C,E
Rationale: B: Gloves are removed first due to high contamination risk, followed by hand hygiene. D: Eye protection is removed next. A: Gown is removed before leaving. C: Mask is removed at the doorway. E: Final hand hygiene ensures cleanliness.
A female client talks to the nurse in the provider's office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?
- A. I am the one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occur more frequently.'
- B. My fibroids are noncancerous tumors that grow slowly.'
- C. My associated problems I have had are pelvic pressure and pain, urinary incontinence, and constipation.'
- D. Fibroids that cause no problems still need to be taken out.'
Correct Answer: D
Rationale: Fibroids that cause no findings may require only 'watchful waiting' with no treatment. Only when the client's findings become disturbing to them would surgical interventions be considered.